July 9, 2009
Wedding Bells for GAVI, the World Bank and the Global Fund?
By Ruth Levine
The global health meeting circuit is abuzz with discussions about whether the World Bank, the GAVI Alliance and the Global Fund to Fight AIDS, TB and Malaria will be able to forge a partnership to effectively support health system strengthening in low-income countries – and how that might happen through some undefined activity called “joint programming.” Paris in May, Venice in June, Washington in July. . . the conversation goes on and on, presumably with the intention of coming up with a mutually-agreed plan within the next several months.
The impetus to mobilize money and technical expertise to support improved health sector performance is strong. For the past several years a combination of evidence and anecdote has revved up concerns that (a) donor funding for health organized into disease-, population- or intervention-specific pots can cause problems and distortions, such as inefficiencies in information systems and drug supply chains, and poaching of health workers; and (b) ambitious disease-, population- and intervention-specific goals can’t be achieved without robust systems for financing, regulating and delivering public and private health care.
The drum beat for “health systems strengthening” has gotten louder and louder, most recently in the work of the High Level Task Force on Innovative International Financing for Health Systems and the WHO-led effort Maximizing Positive Synergies between Health Systems and Global Health Initiatives.
That explains the “systems” focus – but not why GAVI, the Global Fund and the World Bank are now gazing fondly into each other’s eyes. They are, perhaps, eager to be in the right place at the right time – that is, in position to catch any new resources if and when they are made available for health systems – and they think the odds are best if they stand close to one another.
They have a mandate to mingle, courtesy of the High Level Task Force, which recommended: “Establish a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies.”
The Task Force described the three-way marriage in a way that manages to eliminate the “others” mentioned in the recommendation, but brings in World Health Organization as the maid of honor.
For pooling of resources at the global level the announced intention of the Global Fund, the GAVI Alliance (GAVI) and the World Bank to develop a coordinated, streamlined programming approach to support health systems strengthening provides an attractive way forward. The three agencies would receive funds from existing traditional
DAH [development assistance for health] and innovative sources, but work under a new collaborative agreement for a health systems platform.New commitments from donors and private entities to fund these agencies will need to be matched by commitments to demonstrate significant progress on improving ways of working and achieving results. WHO remains committed to facilitating this process.
Thus affianced, does the trio have what it takes to be a successful funding platform – and does it make sense for them to sort out the arrangements themselves? To start with, it’s not immediately evident that GAVI and the Global Fund – two entities that epitomize disease- and intervention-specific funding pots – are the perfect champions of health systems, although they’re working hard to prove otherwise. They also unfortunately don’t have an unblemished record of success, either in their main line of work or more recent health system strengthening “windows.” For example, the Global Fund evaluation brings into question the effectiveness of Country Coordinating Mechanisms in generating technically sound proposals that reflect country priorities. For its part, GAVI has been stung by concerns about the impact of high-level incentives for increasing childhood immunization and reports of troubles that have affected the support to health systems.
And then there is the World Bank. While arguably better positioned by virtue of engagement with national policy and self-proclaimed comparative advantage in financing and systems issues, the Bank itself does not exactly have an enviable track record in its portfolio of health operations aimed at improving the functioning of weak systems. More often than one might like to think, technically sophisticated financing and delivery reforms have been undermined by all manner of real-world constraints, from politics to potholes. The Bank also has some trouble keeping track of where the borrowed money goes – what results are achieved and even (as the author of The World Bank and the Gods of Lending tells it) what pockets are filled.
On the way to the altar, none of these shortcomings and questions seems to be getting in the way. With the High Level Task Force acting like parents arranging a marriage, the multiple international meetings permitting the happy threesome to get to know each other better, and the dowry being arranged behind the scenes, I’m guessing we’ll see an announcement about a new health systems strengthening initiative within the next six months. Both GAVI and the Global Fund have Board meetings in November, and presumably will want sign-off at that time.
Between now and then, it’s likely that a small number of individuals from each organization will sort out who does what, how much money each party gets, and what the governance looks like. They will do their best to work collaboratively, if for no other reason than the fear of failing; at the same time, they will be balancing strong guidance from their management to look after institutional interests, with priority on reputation and resources. Somewhere in the mix will be a consultation or two. The final plan will emerge as a fait accompli, to the sounds of polite applause and a champagne cork.
A better alternative would be a more open and inclusive (and potentially time-consuming) process in which independent perspectives – most importantly from the affected countries – would be solicited and used to inform design of a health systems strengthening initiative that would not have a predetermined outcome. An open discussion could be marshaled about the strengths and weaknesses of the three organizations for health systems development, building on the considerable knowledge now available through the various evaluations and assessments. Any proposal the organizations themselves develop could be put into the sunlight before the deal is done.
The current attention to health systems represents a huge opportunity – not an opportunity for these three organizations, as it might appear, but rather for the health workers and households in 75 or more poor countries.
Speak now or forever hold your peace.
July 10, 2009 at 7:52 am
Great blog Ruth. I especially agree with the point you make about the importance of applying the knowledge from the evaluations of the Global Fund, GAVI and the WBank’s health portfolio – so that the new platform can reflect the insights about what aspect of each aid “model” is working, and which bits aren’t. I sincerely hope that whatever model the global community comes up with – at least learns from the old mistakes (or weaknesses). Let’s make new mistakes!!
And the point you make about opening up the discussions to include the beneficiaries (or users) of the planned support is equally critical.
In reading the material collected at country level for the Global Fund evaluation – it was strikingly clear that how an aid model looks from Geneva (or Venice or Washington) is VERY different from how it looks, feels and works in the respective countries. The CCMs for example seem fine from a distance, but up close, not so much. It would be a big mistake to not get these valuable perspectives from the countries where the new HSS support is intended to work.
July 10, 2009 at 4:25 pm
I read your blog with great interest. Of course it’s very easy to be sceptical about these initiatives and we certainly don’t underestimate the difficulties of achieving results, but I would like to suggest to you that the driving force behind this effort is a recognition by all three agencies that we can do a lot better, that we owe it to our countries to decrease fragmentation and therefore avoid new vertical programs aka HSS, and we owe it to our stakeholders to deliver value for money.
We are actually consulting a lot, while recognizing also that we need to move forward. We talk regularly with the CSOs in the IHP+ steering process where both Northern and Southern CSOs are participating; we had a wide-ranging discussion recently in D.C which included donors, including USAID, CSOs and countries and we have also been talking with many countries, most recently in Bamako.
July 11, 2009 at 3:20 am
Stimulating comments on the World Bank-GAVI-GFATM-WHO dialogue. I hope we will prove you wrong on just \a dialogue or two\. Our recent workshop placed a lot of emphasis on doing something that meets country needs and fits with country plans, ala Paris/Accra, and also wider consultation. We’ve posted that workshop on the web and welcome feedback.
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/0,,contentMDK:22231443~menuPK:2643981~pagePK:64020865~piPK:51164185~theSitePK:282511,00.html
July 14, 2009 at 9:54 am
Excellent discussion of the move towards harmonization of funding for more effective health systems strengthening. While, in general, I think better coordination is always a good thing, I am not convinced that we have any evidence that shows that poor harmonization is the reason why there are not more robust health systems strengthening efforts.
In my work with countries I see that much depends on the national mechanisms in place to a) identify where the health system requires interventions; b) design and implent interventions that address the issues identified in a; c) monitor effects and steer intervention changes as required and d)do this over 10 years, which is probably (though what evidence do we have?) the time it takes to develop really strong systems.
So donor/lender harmonization is great, but can it be effective without corresponding action at country level? And how can we move from including countries in the discussions to creating really effective systems change processes?
July 19, 2009 at 8:57 am
For a darker view on this topic read:
“Development Aid: The Investment Banks of the Humanitarian Sector”
( http://duvet-dayz.com/archives/2008/10/08/913/ )
July 22, 2009 at 6:42 am
Very commendable Ruth´s paper, as a further contribution for the overall efforts towards maximizing the GHI synergies with National Health System Strengthening. We support especially your penultimate paragraph on the better alternative focussing on the affected countries. Much more could be gained in fact tru building on the countries` experiences/most best practices regarding national ownership, GHI harmonization/fund pooling, health strategic planning and result-based mangement; and including past GF/GAVI/WB and other research institutions (such as The EU/INCO)countries evaluations/assessments.
August 8, 2009 at 2:58 pm
A marriage like that would create economies of scale and should allow more services to be delivered. However turf protection always impedes progress.
August 20, 2009 at 11:55 am
Barbara Stillwell is right (see comment #4) that donor coordination and harmonization are not very useful without “corresponding action at the country level.” For one idea on how funders can encourage corresponding country level action without getting in the face of already overburdened officials, even in countries with limited capacity, see the CGD proposal for Cash-on-Delivery Aid.
September 7, 2009 at 5:44 pm
Countries have the capacity, that may contradicts the arguement of many consulants,donors and implementing agencies that countries have limited capacity to deal with any issues. We need to help this countries identify their assets starting from community level up to the national level. Doing this will identify where the gap is and what area and at what evel of capacity areas donors will need to support and build. When supporting a country conduct an asset based assessment study Donors will help a country know their srengths (look at skills and talents, resources, system in place (policy, strategies, action plan, national funding from govt and private sectors),organisations involved and can be involved(Civil society organisations, faith organisations, tradional systems) more importantly the country will need to take ownership.